CHF guidelines 2013seminar

2013 ACCF/AHA Guideline for the

Management of Heart Failure

Developed in Collaboration With the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation

© American College of Cardiology Foundation and American Heart Association, Inc.

Dr Manish Ruhela

Clyde W. Yancy and Mariell Jessup

ACCF/AHA Heart Failure Guideline Writing Committee MembersClyde W. Yancy, MD, MSc, FACC, FAHA, Chair†‡

Mariell Jessup, MD, FACC, FAHA, Vice Chair*†

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal

information.

†ACCF/AHA Representative. ‡ACCF/AHA Task Force on Practice Guidelines Liaison. §American College of Physicians Representative. ║American College of Chest Physicians

Representative. ¶International Society for Heart and Lung Transplantation Representative. #ACCF/AHA Task Force on Performance Measures Liaison. **American Academy of Family

Physicians Representative. ††Heart Rhythm Society Representative.

Practice Guidelines• ACC/AHA: 1995, 2001, 2005, 2009

my.americanheart.org

Classification of Recommendations and Levels of EvidenceA recommendation with

Level of Evidence B or C

does not imply that the

recommendation is weak.

Many important clinical

questions addressed in

the guidelines do not lend

themselves to clinical

trials. Although

randomized trials are

unavailable, there may be

a very clear clinical

consensus that a

particular test or therapy

is useful or effective.

*Data available from

clinical trials or registries

about the usefulness/

efficacy in different

subpopulations, such as

sex, age, history of

diabetes, history of prior

myocardial infarction,

history of heart failure,

and prior aspirin use.

†For comparative

effectiveness

recommendations (Class I

and IIa; Level of Evidence

A and B only), studies

that support the use of

comparator verbs should

involve direct

comparisons of the

treatments or strategies

being evaluated.

Definition HF is a complex clinical syndrome that results from any structural or functional

impairment of ventricular filling or ejection of blood.

The cardinal manifestations of HF are dyspnea and fatigue, which may limitexercise tolerance, and fluid retention, which may lead to pulmonary and/or

splanchnic congestion and/or peripheral edema.

Some patients have exercise intolerance but little evidence of fluid retention,

whereas others complain primarily of edema, dyspnea, or fatigue. Because somepatients present without signs or symptoms of volume overload, the term “heartfailure” is preferred over “congestive heart failure.”

There is no single diagnostic test for HF because it is largely a clinical diagnosisbased on a careful history and physical examination.

Classification of Heart Failure

ACCF/AHA Stages of HF NYHA Functional Classification

A At high risk for HF but without structural

heart disease or symptoms of HF.

None

B Structural heart disease but without signs

or symptoms of HF.

I No limitation of physical activity.

Ordinary physical activity does not cause

symptoms of HF.

C Structural heart disease with prior or

current symptoms of HF.

I No limitation of physical activity.

Ordinary physical activity does not cause

symptoms of HF.

II Slight limitation of physical activity.

Comfortable at rest, but ordinary physical

activity results in symptoms of HF.

III Marked limitation of physical activity.

Comfortable at rest, but less than ordinary

activity causes symptoms of HF.

IV Unable to carry on any physical activity

without symptoms of HF, or symptoms of

HF at rest.

D Refractory HF requiring specialized

interventions.

Definition of Heart FailureClassification Ejection

Fraction

Description

I. Heart Failure with

Reduced Ejection Fraction

(HFrEF)

≤40% Also referred to as systolic HF. Randomized clinical trials have

mainly enrolled patients with HFrEF and it is only in these patients

that efficacious therapies have been demonstrated to date.

II. Heart Failure with

Preserved Ejection

Fraction (HFpEF)

≥50% Also referred to as diastolic HF. The diagnosis of HFpEF is

challenging because it is largely one of excluding other potential

noncardiac causes of symptoms suggestive of HF. To date,

efficacious therapies have not been identified.

a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their

characteristics, treatment patterns, and outcomes appear similar to

those of patient with HFpEF.

b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF

previously had HFrEF. These patients with improvement or recovery

in EF may be clinically distinct from those with persistently

preserved or reduced EF. Further research is needed to better

characterize these patients.

I. Initial and Serial Evaluation of the HF Patient

(including HFpEF)

II. Treatment of Stage A thru D Heart Failure

(including HFpEF)

III. The Hospitalized Patient

IV. Surgical/Percutaneous/Transcatheter Interventional Treatments

V. Coordinating Care for Patients With Chronic HF

VI. Quality Metrics/Performance Measures

Outline

Clinical Evaluation

Initial and Serial Evaluation of the HF Patient

Initial and Serial Evaluation of

the HF Patient

Guideline for HF

History and Physical

Examination


A thorough history and physical examination should beobtained/performed in patients presenting with HF toidentify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF.

In patients with idiopathic DCM, a 3-generational family history should be obtained to aid in establishing the diagnosis of familial DCM.

Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.

History and Physical ExaminationI IIa IIb III

I IIa IIb III

I IIa IIb III

Risk Scoring


Risk Scoring

Validated multivariable risk scores can be useful to estimate subsequent risk of mortality in ambulatory or hospitalized patients with HF.

I IIa IIb III

Risk Scores to Predict Outcomes in HF

Risk Score Reference (from full-text guideline)/Link

Chronic HF

All patients with chronic HF

Seattle Heart Failure Model (204) / http://SeattleHeartFailureModel.org

Heart Failure Survival Score (200) / http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc-

37354.shtml

CHARM Risk Score (207)

CORONA Risk Score (208)

Specific to chronic HFpEF

I-PRESERVE Score (202)

Acutely Decompensated HF

ADHERE Classification and Regression

Tree (CART) Model

(201)

American Heart Association Get With the

Guidelines Score

(206) /

http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidel

inesHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-The-

Guidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jsp

EFFECT Risk Score (203) / http://www.ccort.ca/Research/CHFRiskModel.aspx

ESCAPE Risk Model and Discharge Score (215)

OPTIMIZE HF Risk-Prediction Nomogram (216)

http://seattleheartfailuremodel.org/

http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc-37354.shtml

http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidelinesHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-The-Guidelines-Heart-Failure-Home- Page_UCM_306087_SubHomePage.jsp

http://www.ccort.ca/Research/CHFRiskModel.aspx

Seattle Heart Failure Model

www.SeattleHeartFailureModel.org Levy WC et al. Circulation 2006;113:1424-1433

Diagnostic Tests


Diagnostic Tests

Initial lab. evaluation of patients presenting with HF should include CBC, urinalysis, electrolytes (including calcium and magnesium), BUN, serum creatinine, glucose, fasting lipid profile, LFTs, and thyroid-stimulating hormone.

Serial monitoring, when indicated, should include serum electrolytes and renal function.

I IIa IIb III

I IIa IIb III

Diagnostic Tests (cont.)

A 12-lead ECG should be performed initially on all patients presenting with HF.

Screening for hemochromatosis or HIV is reasonable in selected patients who present with HF.

Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Biomarkers

Ambulatory/Outpatient


Ambulatory/Outpatient

In ambulatory patients with dyspnea, measurement of BNP or NT-proBNP is useful to support clinical decision making regarding the diagnosis of HF, especially in the setting of clinical uncertainty.

Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF.

I IIa IIb III

I IIa IIb III

Ambulatory/Outpatient (cont.)

BNP- or NT-proBNP guided HF therapy can be useful to achieve optimal dosing of GDMT in selected clinically euvolemic patients followed in a well-structured HF disease management program.

The usefulness of serial measurement of BNP or NT-proBNP to reduce hospitalization or mortality in patients with HF is not well established.

Measurement of other clinically available tests such as biomarkers of myocardial injury may be considered for additive risk stratification in patients with chronic HF.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Biomarkers

Hospitalized/Acute


Hospitalized/Acute

Measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.

Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF.

I IIa IIb III

I IIa IIb III

Hospitalized/Acute (cont.)

The usefulness of BNP- or NT-proBNP guided therapy for acutely decompensated HF is not well-established.

Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with acutely decompensated HF.

I IIa IIb III

I IIa IIb III

Recommendations for Biomarkers in HFBiomarker, Application Setting COR LOE

Natriuretic peptides

Diagnosis or exclusion of HFAmbulatory,

AcuteI A

Prognosis of HFAmbulatory,

AcuteI A

Achieve GDMT Ambulatory IIa B

Guidance of acutely decompensated

HF therapyAcute IIb C

Biomarkers of myocardial injury

Additive risk stratificationAcute,

Ambulatory I A

Biomarkers of myocardial fibrosis

Additive risk stratification

Ambulatory IIb B

AcuteIIb A

Causes for Elevated Natriuretic Peptide

Levels

Cardiac Noncardiac

Heart failure

Acute coronary syndrome

Heart muscle disease, including

LVH

Valvular heart disease

Pericardial disease

Atrial fibrillation

Myocarditis

Cardiac surgery

Cardioversion

Advancing age

Anemia

Renal failure

Pulmonary causes: obstructive

sleep apnea, severe pneumonia,

pulmonary hypertension

Critical illness

Bacterial sepsis

Severe burns

Toxic-metabolic insults, including

cancer chemotherapy

Noninvasive Cardiac Imaging


Noninvasive Cardiac ImagingPatients with suspected or new-onset HF, or presenting with acute decompensated HF, should undergo a C x-ray to assess heart size and pulmonary congestion, and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patients’ symptoms.

A 2-D echo with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function.

Repeat measurement of EF and severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Noninvasive Cardiac Imaging (cont.)

Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with de novo HF who have known CAD and no angina unless the patient is not eligible for revascularization of any kind.

Viability assessment is reasonable in select situations when planning revascularization in HF patients with CAD.

Radionuclide ventriculography or MRI can be useful to assess LVEF and volume when echocardiography is inadequate.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Noninvasive Cardiac Imaging (cont.)

MRI is reasonable when assessing myocardial infiltrative processes or scar burden.

Routine repeat measurement of LV function assessment in the absence of clinical status change or treatment interventions should not be performed.

I IIa IIb III

No Benefit

I IIa IIb III

Recommendations for Noninvasive Imaging

Recommendation COR LOE

Patients with suspected, acute, or new-onset HF should undergo a chest x-

rayI C

A 2-D echo with Doppler should be performed for initial evaluation of HF I C

Repeat measurement of EF is useful in patients with HF who have had a

significant change in clinical status or received treatment that might affect

cardiac function, or for consideration of device therapy

I C

Noninvasive imaging to detect myocardial ischemia and viability is

reasonable in HF and CADIIa C

Viability assessment is reasonable before revascularization in HF patients

with CADIIa B

Radionuclide ventriculography or MRI can be useful to assess LVEF and

volume IIa C

MRI is reasonable when assessing myocardial infiltration or scar IIa B

Routine repeat measurement of LV function assessment should not be

performed

III: No

BenefitB

Invasive Evaluation


Invasive EvaluationInvasive hemodynamic monitoring with a pulmonary artery catheter should beperformed to guide therapy in patients who have respiratory distress or clinicalevidence of impaired perfusion in whom the adequacy or excess of intracardiac fillingpressures cannot be determined from clinical assessment.

Invasive hemodynamic monitoring can be useful for carefully selected patients withacute HF who have persistent symptoms despite empiric adjustment of standardtherapies and

a. whose fluid status, perfusion, or systemic or pulmonary vascular resistance isuncertain;

b. whose systolic pressure remains low, or is associated with symptoms, despiteinitial therapy;

c. whose renal function is worsening with therapy;

d. who require parenteral vasoactive agents; or

e. who may need consideration for MCS or transplantation.

I IIa IIb III

I IIa IIb III

Invasive Evaluation (cont.)

When ischemia may be contributing to HF, coronary arteriographyis reasonable for patients eligible for revascularization.

Endomyocardial biopsy can be useful in patients presenting withHF when a specific diagnosis is suspected that would influencetherapy.

I IIa IIb III

I IIa IIb III

Invasive Evaluation (cont.)

Routine use of invasive hemodynamic monitoring is notrecommended in normotensive patients with acutedecompensated HF and congestion with symptomatic responseto diuretics and vasodilators.

Endomyocardial biopsy should not be performed in the routineevaluation of patients with HF.

I IIa IIb III

No Benefit

I IIa IIb III

Harm

Recommendations for Invasive Evaluation


Monitoring with a pulmonary artery catheter should be performed in patients

with respiratory distress or impaired systemic perfusion when clinical

assessment is inadequate

I C

Invasive hemodynamic monitoring can be useful for carefully selected

patients with acute HF with persistent symptoms and/or when hemodynamics

are uncertain

IIa C

When coronary ischemia may be contributing to HF, coronary arteriography

is reasonable IIa C

Endomyocardial biopsy can be useful in patients with HF when a specific

diagnosis is suspected that would influence therapyIIa C

Routine use of invasive hemodynamic monitoring is not recommended in

normotensive patients with acute HF

III: No

Benefit

B

Endomyocardial biopsy should not be performed in the routine evaluation of

HFIII: Harm C

Treatment of Stages A to D

Guideline for HF

Stages, Phenotypes and Treatment of HF

STAGE AAt high risk for HF but

without structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs or

symptoms of HF

THERAPY

Goals

Control symptoms

Improve HRQOL

Prevent hospitalization

Prevent mortality

Strategies

Identification of comorbidities

Treatment

Diuresis to relieve symptoms

of congestion

Follow guideline driven

indications for comorbidities,

e.g., HTN, AF, CAD, DM

Revascularization or valvular

surgery as appropriate

STAGE CStructural heart disease

with prior or current

symptoms of HF

THERAPYGoals Control symptoms Patient education Prevent hospitalization Prevent mortality

Drugs for routine use Diuretics for fluid retention ACEI or ARB Beta blockers Aldosterone antagonists

Drugs for use in selected patients Hydralazine/isosorbide dinitrate ACEI and ARB Digoxin

In selected patients CRT ICD Revascularization or valvular

surgery as appropriate

STAGE DRefractory HF

THERAPY

Goals

Prevent HF symptoms

Prevent further cardiac

remodeling

Drugs

ACEI or ARB as

appropriate

Beta blockers as

appropriate

In selected patients

ICD

Revascularization or

valvular surgery as

appropriate

e.g., Patients with:

Known structural heart disease and

HF signs and symptoms

HFpEF HFrEF

THERAPY

Goals

Heart healthy lifestyle

Prevent vascular,

coronary disease

Prevent LV structural

abnormalities

Drugs

ACEI or ARB in

appropriate patients for

vascular disease or DM

Statins as appropriate

THERAPYGoals Control symptoms Improve HRQOL Reduce hospital

readmissions Establish patient’s end-

of-life goals

Options Advanced care

measures Heart transplant Chronic inotropes Temporary or permanent

MCS Experimental surgery or

drugs Palliative care and

hospice ICD deactivation

Refractory symptoms of HF at rest, despite GDMT

At Risk for Heart Failure Heart Failure


Marked HF symptoms at

rest

Recurrent hospitalizations

despite GDMT


Previous MI

LV remodeling including

LVH and low EF

Asymptomatic valvular

disease


HTN

Atherosclerotic disease

DM

Obesity

Metabolic syndrome

or

Patients

Using cardiotoxins

With family history of

cardiomyopathy

Development of

symptoms of HFStructural heart

disease

Stage A


Stage A

Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF.

Other conditions that may lead to or contribute to HF, such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents, should be controlled or avoided.

I IIa IIb III

I IIa IIb III

Stage B


Stage B

In all patients with a recent or remote history of MI or ACS and reduced EF, ACE inhibitors should be used to prevent symptomatic HF and reduce mortality. In patients intolerant of ACE inhibitors, ARBs are appropriate unless contraindicated.

In all patients with a recent or remote history of MI or ACS and reduced EF, evidence-based beta blockers should be used to reduce mortality.

In all patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and cardiovascular events.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Stage B (cont.)

In patients with structural cardiac abnormalities, including LV hypertrophy, in the absence of a history of MI or ACS, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF.

ACE inhibitors should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI.

Beta blockers should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Stage B (cont.)

To prevent SCD, placement of an ICD is reasonable in patients withasymptomatic ischemic cardiomyopathy who are at least 40 dayspost-MI, have an LVEF of 30% or less, are on appropriate medicaltherapy and have reasonable expectation of survival with a goodfunctional status for more than 1 year.

Nondihydropyridine calcium channel blockers with negativeinotropic effects may be harmful in asymptomatic patients withlow LVEF and no symptoms of HF after MI.

I IIa IIb III

I IIa IIb III

Harm

Recommendations for Treatment of Stage B HF

Recommendations COR LOE

In patients with a history of MI and reduced EF, ACE inhibitors or

ARBs should be used to prevent HFI A

In patients with MI and reduced EF, evidence-based beta blockers

should be used to prevent HFI B

In patients with MI, statins should be used to prevent HF I A

Blood pressure should be controlled to prevent symptomatic HF I A

ACE inhibitors should be used in all patients with a reduced EF to

prevent HFI A

Beta blockers should be used in all patients with a reduced EF to

prevent HFI C

An ICD is reasonable in patients with asymptomatic ischemic

cardiomyopathy who are at least 40 d post-MI, have an LVEF

≤30%, and on GDMT

IIa B

Nondihydropyridine calcium channel blockers may be harmful in

patients with low LVEF III: Harm C

Stage C


Nonpharmacological

Interventions


Stage C: Nonpharmacological

InterventionsPatients with HF should receive specific education tofacilitate HF self-care.

Exercise training (or regular physical activity) isrecommended as safe and effective for patients with HF whoare able to participate to improve functional status.

Sodium restriction is reasonable for patients withsymptomatic HF to reduce congestive symptoms.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Stage C: Nonpharmacological

Interventions (cont.)

Continuous positive airway pressure (CPAP) can be beneficial to increase LVEF and improve functional status in patients with HF and sleep apnea.

Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, and mortality.

I IIa IIb III

I IIa IIb III

Pharmacological Treatment for

Stage C HFrEF


Pharmacological Treatment for Stage

C HFrEF

Measures listed as Class I recommendations for patients in stages A and B are recommended where appropriate for patients in stage C. (Levels of Evidence: A, B, and C as appropriate)

GDMT as depicted in Figure 1 should be the mainstay of pharmacological therapy for HFrEF.

I IIa IIb III

I IIa IIb III

See

recommendations

for stages A, B,

and C LOE for

LOE

Pharmacologic Treatment for Stage C HFrEFHFrEF Stage C

NYHA Class I – IV

Treatment:

For NYHA class II-IV patients.

Provided estimated creatinine

>30 mL/min and K+ <5.0 mEq/dL

For persistently symptomatic

African Americans,

NYHA class III-IV

Class I, LOE A

ACEI or ARB AND

Beta Blocker

Class I, LOE C

Loop Diuretics

Class I, LOE A

Hydral-Nitrates

Class I, LOE A

Aldosterone

Antagonist

AddAdd Add

For all volume overload,

NYHA class II-IV patients


Stage C HFrEF (cont.)

Diuretics are recommended in patients with HFrEF who haveevidence of fluid retention, unless contraindicated, to improvesymptoms.

ACE inhibitors are recommended in patients with HFrEF and currentor prior symptoms, unless contraindicated, to reduce morbidity andmortality.

ARBs are recommended in patients with HFrEF with current or priorsymptoms who are ACE inhibitor-intolerant, unless contraindicated,to reduce morbidity and mortality.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Drugs Commonly Used for HFrEF

(Stage C HF)

Drug Initial Daily Dose(s) Maximum Doses(s)Mean Doses Achieved in

Clinical Trials

ACE Inhibitors

Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d (421)

Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d (412)

Fosinopril 5 to 10 mg once 40 mg once ---------

Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d (444)

Perindopril 2 mg once 8 to 16 mg once ---------

Quinapril 5 mg twice 20 mg twice ---------

Ramipril 1.25 to 2.5 mg once 10 mg once ---------

Trandolapril 1 mg once 4 mg once ---------

ARBs

Candesartan 4 to 8 mg once 32 mg once 24 mg/d (419)

Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d (420)

Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d (109)

Aldosterone Antagonists

Spironolactone 12.5 to 25 mg once 25 mg once or twice 26 mg/d (424)

Eplerenone 25 mg once 50 mg once 42.6 mg/d (445)

Drugs Commonly Used for HFrEF

(Stage C HF) (cont.)

Drug Initial Daily Dose(s) Maximum Doses(s)Mean Doses Achieved in

Clinical Trials

Beta Blockers

Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d (118)

Carvedilol 3.125 mg twice 50 mg twice 37 mg/d (446)

Carvedilol CR 10 mg once 80 mg once ---------

Metoprolol succinate

extended release

(metoprolol CR/XL)

12.5 to 25 mg once 200 mg once 159 mg/d (447)

Hydralazine & Isosorbide Dinitrate

Fixed dose combination

(423)

37.5 mg hydralazine/

20 mg isosorbide

dinitrate 3 times daily

75 mg hydralazine/

40 mg isosorbide

dinitrate 3 times daily

~175 mg hydralazine/90 mg

isosorbide dinitrate daily

Hydralazine and

isosorbide dinitrate (448)

Hydralazine: 25 to 50

mg, 3 or 4 times daily

and isorsorbide

dinitrate:

20 to 30 mg

3 or 4 times daily

Hydralazine: 300 mg

daily in divided doses

and isosorbide dinitrate

120 mg daily in

divided doses

---------



ARBs are reasonable to reduce morbidity and mortality asalternatives to ACE inhibitors as first-line therapy for patients withHFrEF, especially for patients already taking ARBs for otherindications, unless contraindicated.

Addition of an ARB may be considered in persistently symptomaticpatients with HFrEF who are already being treated with an ACEinhibitor and a beta blocker in whom an aldosterone antagonist isnot indicated or tolerated.

I IIa IIb III

I IIa IIb III



Routine combined use of an ACE inhibitor, ARB, and aldosteroneantagonist is potentially harmful for patients with HFrEF.

Use of 1 of the 3 beta blockers proven to reduce mortality (i.e.,bisoprolol, carvedilol, and sustained-release metoprolol succinate)is recommended for all patients with current or prior symptoms ofHFrEF, unless contraindicated, to reduce morbidity and mortality.

I IIa IIb III

I IIa IIb III

Harm



Aldosterone receptor antagonists are recommended inpatients with NYHA class II-IV and who have LVEF of 35% orless, unless contraindicated, to reduce morbidity and mortality.

Patients with NYHA class II should have a history of priorcardiovascular hospitalization or elevated plasma natriureticpeptide levels to be considered for aldosterone receptorantagonists.

Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dLor less in women (or estimated glomerular filtration rate >30mL/min/1.73m2) and potassium should be less than 5.0 mEq/L.

I IIa IIb III



Aldosterone receptor antagonists are recommended to reducemorbidity and mortality following an acute MI in patients whohave LVEF of 40% or less who develop symptoms of HF or whohave a history of diabetes mellitus, unless contraindicated.

Inappropriate use of aldosterone receptor antagonists ispotentially harmful because of life-threatening hyperkalemia orrenal insufficiency when serum creatinine greater than 2.5mg/dL in men or greater than 2.0 mg/dL in women (orestimated glomerular filtration rate <30 mL/min/1.73m2),and/or potassium above 5.0 mEq/L.

I IIa IIb III

I IIa IIb III

Harm



The combination of hydralazine and isosorbide dinitrate isrecommended to reduce morbidity and mortality for AfricanAmericans patients with NYHA class III–IV HFrEF receivingoptimal therapy with ACE inhibitors and beta blockers, unlesscontraindicated.

A combination of hydralazine and isosorbide dinitrate can beuseful to reduce morbidity or mortality in patients with currentor prior symptomatic HFrEF who cannot be given an ACEinhibitor or ARB because of drug intolerance, hypotension, orrenal insufficiency, unless contraindicated.

I IIa IIb III

I IIa IIb III



Digoxin can be beneficial in patients with HFrEF, unlesscontraindicated, to decrease hospitalizations for HF.

Patients with chronic HF with AF and an additional risk factorfor cardioembolic stroke (history of hypertension, diabetesmellitus, previous stroke or transient ischemic attack, or ≥75years of age) should receive chronic anticoagulant therapy (inthe absence of contraindications to anticoagulation).

I IIa IIb III

I IIa IIb III



The selection of an anticoagulant agent for AF should beindividualized on the basis of risk factors, cost, tolerability,patient preference, potential for drug interactions, and otherclinical characteristics, including time in the internationalnormalized rate therapeutic ration if the patient has beentaking warfarin.

Chronic anticoagulation is reasonable for patients with chronicHF who have AF but are without an additional risk factor forcardioembolic stroke (in the absence of contraindications toanticoagulation).

I IIa IIb III

I IIa IIb III



Anticoagulation is not recommended in patients with chronicHFrEF without AF, a prior thromboembolic event, or acardioembolic source.

Statins are not beneficial as adjunctive therapy whenprescribed solely for the diagnosis of HF in the absence of otherindications for their use.

Omega-3 PUFA supplementation is reasonable to use asadjunctive therapy in patients with NYHA class II-IV symptomsand HFrEF or HFpEF, unless contraindicated, to reducemortality and cardiovascular hospitalizations.

I IIa IIb III

No Benefit

I IIa IIb III

No Benefit

I IIa IIb III



Nutritional supplements as treatment for HF are notrecommended in patients with current or prior symptoms ofHFrEF.

Hormonal therapies other than to correct deficiencies are notrecommended for patients with current or prior symptoms ofHFrEF.

Drugs known to adversely affect the clinical status of patientswith current or prior symptoms of HFrEF are potentially harmfuland should be avoided or withdrawn whenever possible (e.g.,most antiarrhythmic drugs, most calcium channel blockingdrugs (except amlodipine), NSAIDs, or TZDs).

No Benefit

I IIa IIb III

I IIa IIb III

I IIa IIb III

No Benefit

Harm



Long-term use of infused positive inotropic drugs is potentiallyharmful for patients with HFrEF, except as palliation for patientswith end-stage disease who cannot be stabilized with standardmedical treatment (see recommendations for stage D).

Calcium channel blocking drugs are not recommended asroutine treatment for patients with HFrEF.

Harm

I IIa IIb III

I IIa IIb III

No Benefit


Stage C HFpEF Systolic and diastolic blood pressure should be controlled inpatients with HFpEF in accordance with published clinicalpractice guidelines to prevent morbidity.

Diuretics should be used for relief of symptoms due to volumeoverload in patients with HFpEF.

Coronary revascularization is reasonable in patients with CAD inwhom symptoms (angina) or demonstrable myocardialischemia is judged to be having an adverse effect onsymptomatic HFpEF despite GDMT.

I IIa IIb III

I IIa IIb III

I IIa IIb III


Stage C HFpEF (cont.)

Management of AF according to published clinical practiceguidelines in patients with HFpEF is reasonable to improvesymptomatic HF.

The use of beta-blocking agents, ACE inhibitors, and ARBs inpatients with hypertension is reasonable to control bloodpressure in patients with HFpEF.

I IIa IIb III

I IIa IIb III


Stage C HFpEF (cont.)

The use of ARBs might be considered to decreasehospitalizations for patients with HFpEF.

Routine use of nutritional supplements is not recommended forpatients with HFpEF.

I IIa IIb III

No Benefit

I IIa IIb III

Pharmacological Therapy for

Management of Stage C HFrEFRecommendations COR LOE

Diuretics

Diuretics are recommended in patients with HFrEF with fluid

retention I C

ACE Inhibitors

ACE inhibitors are recommended for all patients with HFrEF I A

ARBs

ARBs are recommended in patients with HFrEF who are ACE

inhibitor intolerant I A

ARBs are reasonable as alternatives to ACE inhibitor as first

line therapy in HFrEFIIa A

The addition of an ARB may be considered in persistently

symptomatic patients with HFrEF on GDMTIIb A

Routine combined use of an ACE inhibitor, ARB, and

aldosterone antagonist is potentially harmful III: Harm C


Management of Stage C HFrEF (cont.)Recommendations COR LOE

Beta Blockers

Use of 1 of the 3 beta blockers proven to reduce mortality is

recommended for all stable patientsI A

Aldosterone Antagonists

Aldosterone receptor antagonists are recommended in

patients with NYHA class II-IV HF who have LVEF ≤35% I A

Aldosterone receptor antagonists are recommended in

patients following an acute MI who have LVEF ≤40% with

symptoms of HF or DM

I B

Inappropriate use of aldosterone receptor antagonists may be

harmful

III:

HarmB

Hydralazine and Isosorbide Dinitrate

The combination of hydralazine and isosorbide dinitrate is

recommended for African-Americans, with NYHA class III–

IV HFrEF on GDMT

I A

A combination of hydralazine and isosorbide dinitrate can be

useful in patients with HFrEF who cannot be given ACE

inhibitors or ARBs

IIa B

Pharmacologic Therapy for

Management of Stage C HFrEF (cont.)Recommendations COR LOE

Digoxin

Digoxin can be beneficial in patients with HFrEF IIa B

Anticoagulation

Patients with chronic HF with permanent/persistent/paroxysmal AF and an

additional risk factor for cardioembolic stroke should receive chronic

anticoagulant therapy*

I A

The selection of an anticoagulant agent should be individualized I C

Chronic anticoagulation is reasonable for patients with chronic HF who have

permanent/persistent/paroxysmal AF but without an additional risk factor for

cardioembolic stroke*

IIa B

Anticoagulation is not recommended in patients with chronic HFrEF without

AF, prior thromboembolic event, or a cardioembolic source

III: No

BenefitB

Statins

Statins are not beneficial as adjunctive therapy when prescribed solely for HF III: No

BenefitA

Omega-3 Fatty Acids

Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in

HFrEF or HFpEF patients IIa B


Management of Stage C HFrEF (cont.)


Other Drugs

Nutritional supplements as treatment for HF are not recommended

in HFrEF

III: No

BenefitB

Hormonal therapies other than to replete deficiencies are not

recommended in HFrEF

III: No

BenefitC

Drugs known to adversely affect the clinical status of patients with

HFrEF are potentially harmful and should be avoided or

withdrawn

III: Harm B

Long-term use of an infusion of a positive inotropic drug is not

recommended and may be harmful except as palliationIII: Harm C

Calcium Channel Blockers

Calcium channel blocking drugs are not recommended as routine

in HFrEF

III: No

BenefitA

Treatment for Stage C HFpEF


Treatment of HFpEFRecommendations COR LOE

Systolic and diastolic blood pressure should be controlled

according to published clinical practice guidelines I B

Diuretics should be used for relief of symptoms due to

volume overloadI C

Coronary revascularization for patients with CAD in

whom angina or demonstrable myocardial ischemia is

present despite GDMT

IIaC

Management of AF according to published clinical

practice guidelines for HFpEF to improve symptomatic

HF

IIa C

Use of beta-blocking agents, ACE inhibitors, and ARBs

for hypertension in HFpEF IIa C

ARBs might be considered to decrease hospitalizations in

HFpEFIIb B

Nutritional supplementation is not recommended in

HFpEF

III: No

BenefitC

Device Treatment for Stage C

HFrEF


Device Therapy for Stage C HFrEF

ICD therapy is recommended for primary prevention of SCD to reducetotal mortality in selected patients with nonischemic DCM or ischemicheart disease at least 40 days post-MI with LVEF of 35% or less, andNYHA class II or III symptoms on chronic GDMT, who have reasonableexpectation of meaningful survival for more than 1 year.

CRT is indicated for patients who have LVEF of 35% or less, sinusrhythm, left bundle-branch block (LBBB) with a QRS duration of 150 msor greater, and NYHA class II, III, or ambulatory IV symptoms on GDMT.

I IIa IIb III

I IIa IIb III

NYHA Class III/IV

I IIa IIb III

NYHA Class II


(cont.)

ICD therapy is recommended for primary prevention of SCD toreduce total mortality in selected patients at least 40 days post-MI with LVEF less than or equal to 30%, and NYHA class Isymptoms while receiving GDMT, who have reasonableexpectation of meaningful survival for more than 1 year.

CRT can be useful for patients who have LVEF of 35% or less,sinus rhythm, a non-LBBB pattern with a QRS duration of 150ms or greater, and NYHA class III/ambulatory class IV symptomson GDMT.

I IIa IIb III

I IIa IIb III


(cont.)

CRT can be useful for patients who have LVEF of 35% or less,sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, andNYHA class II, III, or ambulatory IV symptoms on GDMT.

CRT can be useful in patients with AF and LVEF of 35% or less onGDMT if a) the patient requires ventricular pacing or otherwisemeets CRT criteria and b) atrioventricular nodal ablation orpharmacological rate control will allow near 100% ventricularpacing with CRT.

I IIa IIb III

I IIa IIb III


(cont.)

CRT can be useful for patients on GDMT who have LVEF of 35%or less, and are undergoing placement of a new or replacementdevice placement with anticipated requirement for significant(>40%) ventricular pacing.

The usefulness of implantation of an ICD is of uncertain benefitto prolong meaningful survival in patients with a high risk ofnonsudden death as predicted by frequent hospitalizations,advanced frailty, or comorbidities such as systemic malignancyor severe renal dysfunction.

I IIa IIb III

I IIa IIb III


(cont.)

CRT may be considered for patients who have LVEF of 35% orless , sinus rhythm, a non-LBBB pattern with a QRS duration of150 ms or greater, and NYHA class II symptoms on GDMT.

CRT may be considered for patients who have LVEF of 30% orless, ischemic etiology of HF, sinus rhythm, LBBB with a QRSduration of 150 ms or greater, and NYHA class I symptoms onGDMT.

I IIa IIb III

I IIa IIb III


(cont.)

CRT is not recommended for patients with NYHA class I or IIsymptoms and non-LBBB pattern with a QRS duration of lessthan 150 ms.

CRT is not indicated for patients whose comorbidities and/orfrailty limit survival with good functional capacity to less than 1year.

I IIa IIb III

I IIa IIb III

No Benefit

No Benefit

Indications for CRT TherapyPatient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or

with implantation of pacing or defibrillation device for special indications

LVEF <35%

Evaluate general health status

Comorbidities and/or frailty

limit survival with good

functional capacity to <1 y

Continue GDMT without

implanted device

Acceptable noncardiac health

Evaluate NYHA clinical status

NYHA class I

LVEF ≤30%

QRS ≥150 ms

LBBB pattern

Ischemic

cardiomyopathy

QRS ≤150 ms

Non-LBBB pattern

NYHA class II

LVEF ≤35%

QRS 120-149 ms

LBBB pattern

Sinus rhythm

QRS ≤150 ms

Non-LBBB pattern

LVEF ≤35%

QRS ≥150 ms

LBBB pattern

Sinus rhythm

LVEF ≤35%

QRS ≥150 ms

Non-LBBB pattern

Sinus rhythm

Colors correspond to the class of recommendations in the ACCF/AHA Table 1.

Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along

with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D

unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and

personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.

NYHA class III &

Ambulatory class IV

LVEF ≤35%

QRS 120-149 ms

LBBB pattern

Sinus rhythm

LVEF ≤35%

QRS 120-149 ms

Non-LBBB pattern

Sinus rhythm

LVEF ≤35%

QRS ≥150 ms

LBBB pattern

Sinus rhythm

LVEF≤35%

QRS ≥150 ms

Non-LBBB pattern

Sinus rhythm

Anticipated to require

frequent ventricular

pacing (>40%)

Atrial fibrillation, if

ventricular pacing is

required and rate

control will result in

near 100%

ventricular pacing

with CRT

Special CRT

Indications

Device Therapy for Stage C HFrEF (cont.)Recommendations COR LOE

ICD therapy is recommended for primary prevention of SCD in selected

patients with HFrEF at least 40 days post-MI with LVEF ≤35%, and NYHA

class II or III symptoms on chronic GDMT, who are expected to live ≥1 year*I A

CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with

a QRS ≥150 msI

A (NYHA

class III/IV)

B (NYHA

class II)

ICD therapy is recommended for primary prevention of SCD in selected

patients with HFrEF at least 40 days post-MI with LVEF ≤30%, and NYHA

class I symptoms while receiving GDMT, who are expected to live ≥1 year*I B

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-

LBBB pattern with a QRS ≥150 ms, and NYHA class III/ambulatory class IV

symptoms on GDMT.

IIa A

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB

with a QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptoms

on GDMT

IIaB

CRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) the

patient requires ventricular pacing or otherwise meets CRT criteria and b) AV

nodal ablation or rate control allows near 100% ventricular pacing with CRT

IIa B


CRT can be useful for patients on GDMT who have LVEF ≤35%, and are

undergoing new or replacement device with anticipated (>40%) ventricular

pacing

IIa C

An ICD is of uncertain benefit to prolong meaningful survival in patients with

high risk of nonsudden death such as frequent hospitalizations, frailty, or severe

comorbidities*

IIbB

CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-

LBBB pattern with QRS 120 to 149 ms, and NYHA class III/ambulatory class IV

on GDMT

IIb B

CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-

LBBB pattern with a QRS ≥150 ms, and NYHA class II symptoms on GDMT IIb B

CRT may be considered for patients who have LVEF ≤30%, ischemic etiology of

HF, sinus rhythm, LBBB with a QRS ≥150 ms, and NYHA class I symptoms on

GDMT

IIb C

CRT is not recommended for patients with NYHA class I or II symptoms and

non-LBBB pattern with QRS <150 ms

III: No

BenefitB

CRT is not indicated for patients whose comorbidities and/or frailty limit

survival to <1 year

III: No

BenefitC

Device Therapy for Stage C HFrEF (cont.)

Stage D


Clinical Events and Findings Useful for

Identifying Patients With Advanced HF

Repeated (≥2) hospitalizations or ED visits for HF in the past year

Progressive deterioration in renal function (e.g., rise in BUN and creatinine)

Weight loss without other cause (e.g., cardiac cachexia)

Intolerance to ACE inhibitors due to hypotension and/or worsening renal function

Intolerance to beta blockers due to worsening HF or hypotension

Frequent systolic blood pressure <90 mm Hg

Persistent dyspnea with dressing or bathing requiring rest

Inability to walk 1 block on the level ground due to dyspnea or fatigue

Recent need to escalate diuretics to maintain volume status, often reaching daily

furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapy

Progressive decline in serum sodium, usually to <133 mEq/L

Frequent ICD shocks

Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21.

Water Restriction


Water Restriction

Fluid restriction (1.5 to 2 L/d) is reasonable in stageD, especially in patients with hyponatremia, toreduce congestive symptoms.

I IIa IIb III

Inotropic Support


Inotropic Support

Until definitive therapy (e.g., coronary revascularization, MCS, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary intravenous inotropic support to maintain systemic perfusion and preserve end-organ performance.

Continuous intravenous inotropic support is reasonable as “bridge therapy” in patients with stage D refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation.

I IIa IIb III

I IIa IIb III

Inotropic Support (cont.)

Short-term, continuous intravenous inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance.

Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control in select patients with stage D despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation.

I IIa IIb III

I IIa IIb III

Inotropic Support (cont.)

Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents, in the absence of specific indications or for reasons other than palliative care, is potentially harmful in the patient with HF.

Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion, and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful.

I IIa IIb III

I IIa IIb III

Harm

Harm

Mechanical Circulatory

Support


Mechanical Circulatory Support

MCS use is beneficial in carefully selected* patients with stage D HFrEF in whom definitive management (e.g., cardiac transplantation) or cardiac recovery is anticipated or planned.

Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices (VADs), is reasonable as a “bridge to recovery” or a “bridge to decision” for carefully selected patients with HFrEF with acute, profound hemodynamic compromise.

Durable MCS is reasonable to prolong survival for carefully selected patients with stage D HFrEF.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Cardiac Transplantation


Cardiac Transplantation

Evaluation for cardiac transplantation is indicated forcarefully selected patients with stage D HF despiteGDMT, device, and surgical management.

I IIa IIb III

The Hospitalized Patient

Guideline for HF

Precipitating Causes of

Decompensated HF


Precipitating Causes of Decompensated

HF

ACS precipitating acute HF decompensation should be promptlyidentified by ECG and serum biomarkers including cardiactroponin testing, and treated optimally as appropriate to theoverall condition and prognosis of the patient.

Common precipitating factors for acute HF should be consideredduring initial evaluation, as recognition of these conditions iscritical to guide appropriate therapy.

I IIa IIb III

I IIa IIb III

Maintenance of GDMT During

Hospitalization


Maintenance of GDMT During

Hospitalization

In patients with HFrEF experiencing a symptomatic exacerbation ofHF requiring hospitalization during chronic maintenance treatmentwith GDMT, it is recommended that GDMT be continued in theabsence of hemodynamic instability or contraindications.

Initiation of beta-blocker therapy is recommended afteroptimization of volume status and successful discontinuation ofintravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stablepatients. Caution should be used when initiating beta blockers inpatients who have required inotropes during their hospital course.

I IIa IIb III

I IIa IIb III

Diuretics in Hospitalized

Patients


Diuretics in Hospitalized Patients

Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity.

If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension.

I IIa IIb III

I IIa IIb III

Diuretics in Hospitalized Patients (cont.)

The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications.

When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either:

a. higher doses of intravenous loop diuretics.

b. addition of a second (e.g., thiazide) diuretic.

I IIa IIb III

I IIa IIb III

Diuretics in Hospitalized Patients (cont.)

Low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood flow.

I IIa IIb III

Parenteral Therapy in

Hospitalized HF


Parenteral Therapy in Hospitalized HF

If symptomatic hypotension is absent, intravenousnitroglycerin, nitroprusside or nesiritide may beconsidered an adjuvant to diuretic therapy for reliefof dyspnea in patients admitted with acutelydecompensated HF.

I IIa IIb III

Venous Thromboembolism

Prophylaxis in Hospitalized

Patients


Venous Thromboembolism Prophylaxis

in Hospitalized Patients

A patient admitted to the hospital with decompensated HF should be treated for venous thromboembolism prophylaxis with an anticoagulant medication if the risk:benefit ratio is favorable.

I IIa IIb III

Inpatient and Transitions of

Care


Inpatient and Transitions of Care

The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early post-discharge outpatient setting to identify appropriate HF patients for GDMT, provide clinicians with useful reminders to advance GDMT, and to assess the clinical response.

I IIa IIb III


Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed:

a. initiation of GDMT if not previously established and not contraindicated;

b. precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support;

c. assessment of volume status and supine/upright hypotension with adjustment of HF therapy, as appropriate;

d. titration and optimization of chronic oral HF therapy;

e. assessment of renal function and electrolytes, where appropriate;

f. assessment and management of comorbid conditions;

g. reinforcement of HF education, self-care, emergency plans, and need for adherence; and

h. consideration for palliative care or hospice care in selected patients.

I IIa IIb III


Multidisciplinary HF disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for HF.

Scheduling an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge is reasonable.

Use of clinical risk prediction tools and/or biomarkers to identify patients at higher risk for postdischarge clinical events is reasonable.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Therapies in the Hospitalized HF Patient


HF patients hospitalized with fluid overload should be treated with

intravenous diureticsI B

HF patients receiving loop diuretic therapy, should receive an initial

parenteral dose greater than or equal to their chronic oral daily dose, then

should be serially adjusted

I B

HFrEF patients requiring HF hospitalization on GDMT should continue

GDMT unless hemodynamic instability or contraindicationsI B

Initiation of beta-blocker therapy at a low dose is recommended after

optimization of volume status and discontinuation of intravenous agents I B

Thrombosis/thromboembolism prophylaxis is recommended for patients

hospitalized with HFI B

Serum electrolytes, urea nitrogen, and creatinine should be measured

during the titration of HF medications, including diureticsI C

Hospital Discharge

Recommendation or Indication COR LOE

Performance improvement systems in the hospital and early postdischarge outpatient setting

to identify HF for GDMTI B

Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits,

the following should be addressed:

a) initiation of GDMT if not done or contraindicated;

b) causes of HF, barriers to care, and limitations in support;

c) assessment of volume status and blood pressure with adjustment of HF therapy;

d) optimization of chronic oral HF therapy;

e) renal function and electrolytes;

f) management of comorbid conditions;

g) HF education, self-care, emergency plans, and adherence; and

h) palliative or hospice care.

I B

Multidisciplinary HF disease-management programs for patients at high risk for hospital

readmission are recommended I B

A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital

discharge is reasonableIIa B

Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is

reasonableIIa B

Surgical/Percutaneous/

Transcatheter Interventional

Treatments of HF

Guideline for HF

Surgical/Percutaneous/Transcatheter

Interventional Treatment of HF


CABG or percutaneous intervention is indicated for HF patients on GDMT with

angina and suitable coronary anatomy especially, significant left main stenosis or left

main equivalent disease

I C

CABG to improve survival is reasonable in patients with mild to moderate LV

systolic dysfunction and significant multivessel CAD or proximal LAD stenosis

when viable myocardium is present

IIa B

CABG or medical therapy is reasonable to improve morbidity and mortality for

patients with severe LV dysfunction (EF <35%), HF and significant CAD IIa B

Surgical aortic valve replacement is reasonable for patients with critical aortic

stenosis and a predicted surgical mortality of no greater than 10%IIa B

Transcatheter aortic valve replacement is reasonable for patients with critical aortic

stenosis who are deemed inoperable IIa B

CABG may be considered in patients with ischemic heart disease, severe LV systolic

dysfunction and suitable coronary anatomy whether or not viable myocardium is

present

IIb B

Transcatheter mitral valve repair or mitral valve surgery for functional mitral

insufficiency is of uncertain benefit IIb B

Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF for

specific indications including intractable HF and ventricular arrhythmias IIb B

Coordinating Care for Patients

With Chronic HF

Guideline for HF

Coordinating Care for Patients With

Chronic HFEffective systems of care coordination with special attention to care transitions should be deployed for every patient with chronic HF that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization.

Every patient with HF should have a clear, detailed and evidence-based plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with Secondary Prevention Guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team.

Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Quality Metrics/Performance

Measures

Guideline for HF

Quality Metrics/Performance Measures

Performance measures based on professionally developed clinical practice guidelines should be used with the goal of improving quality of care for HF.

Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guideline-based quality and performance measures may be beneficial in improving quality of HF care.

I IIa IIb III

I IIa IIb III

• Evidence-based guideline directed diagnosis, evaluation and therapy should be the mainstay for all patients with HF.

• Effective implementation of guideline-directed best quality care reduces mortality, improves QOL and preserves health care resources.

• Ongoing research is needed to answer the remaining questions including: prevention, nonpharmacological therapy of HF including dietary adjustments, treatment of HFpEF, management of hospitalized HF, effective reduction in HF readmissions, more precise use of device-based therapy.

Conclusions

Thankyou

Common Factors That Precipitate Acute Decompensated HF

Nonadherence with medication regimen,

sodium and/or

fluid restriction

Acute myocardial ischemia

Uncorrected high blood pressure

AF and other arrhythmias

Recent addition of negative inotropic drugs (e.g.,

verapamil, nifedipine, diltiazem, beta blockers)

Pulmonary embolus

Initiation of drugs that increase salt retention (e.g.,

steroids, thiazolidinediones, NSAIDs)

Excessive alcohol or illicit drug use

Endocrine abnormalities (e.g., diabetes mellitus,

hyperthyroidism, hypothyroidism)

Concurrent infections (e.g., pneumonia, viral illnesses)

Additional acute cardiovascular disorders (e.g., valve

disease endocarditis, myopericarditis, aortic dissection)

Although optimal patient selection for MCS remains an active area of

investigation, general indications for referral for MCS therapy include

patients with LVEF <25% and

NYHA class III–IV functional status despite GDMT, including,

when indicated, CRT, with either high predicted 1- to 2-year mortality

(e.g., as suggested by markedly reduced peak oxygen consumption

and clinical prognostic scores) or dependence on continuous

parenteral inotropic support.

Patient selection requires a multidisciplinary team of experienced

advanced HF and transplantation cardiologists, cardiothoracic

surgeons, nurses, and ideally, social workers and

palliative care clinicians.

ACCF/AHA/AMA-PCPI 2011 HF Performance

Measurement Set

Measure Description* Care

Setting

Level of

Measurement

1. LVEF

assessment

Percentage of patients aged ≥18 y with a diagnosis of HF for whom the

quantitative or qualitative results of a recent or prior (any time in the

past) LVEF assessment is documented within a 12 mo period

Outpatient Individual

practitioner

2. LVEF

assessment

Percentage of patients aged ≥18 y with a principal discharge diagnosis

of HF with documentation in the hospital record of the results of an

LVEF assessment that was performed either before arrival or during

hospitalization, OR documentation in the hospital record that LVEF

assessment is planned for after discharge

Inpatient Individual

practitioner

Facility

3. Symptom

and activity

assessment

Percentage of patient visits for those patients aged ≥18 y with a

diagnosis of HF with quantitative results of an evaluation of both

current level of activity and clinical symptoms documented

Outpatien

t

Individual

practitioner

*Please refer to the complete measures for comprehensive information, including measure exception.

Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.

ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement Set (cont.)

Measure Description* Care

Setting

Level of

Measurement

4. Symptom

management†

Percentage of patient visits for those patients aged ≥18 y with a

diagnosis of HF and with quantitative results of an evaluation of both

level of activity AND clinical symptoms documented in which patient

symptoms have improved or remained consistent with treatment goals

since last assessment OR patient symptoms have demonstrated

clinically important deterioration since last assessment with a

documented plan of care


practitioner

5. Patient self-

care education†‡

Percentage of patients aged ≥18 y with a diagnosis of HF who were

provided with self-care education on ≥3 elements of education during

≥1 visits within a 12 mo period


practitioner

6. Beta-blocker

therapy for LVSD

(outpatient and

inpatient setting)

Percentage of patients aged ≥18 y with a diagnosis of HF with a

current or prior LVEF <40% who were prescribed beta-blocker

therapy with bisoprolol, carvedilol, or sustained release metoprolol

succinate either within a 12 mo period when seen in the outpatient

setting or at hospital discharge

Inpatient

and

Outpatient

Individual

practitioner

Facility


†Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any other

purpose, e.g., pay for performance, physician ranking or public reporting programs.

‡New measure.


ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement Set (cont.)

Measure Description* Care Setting Level of

Measurement

7. ACE Inhibitor or

ARB Therapy for

LVSD (outpatient and

inpatient setting)

Percentage of patients aged ≥18 y with a diagnosis of HF with a

current or prior LVEF <40% who were prescribed ACE inhibitor or

ARB therapy either within a 12 mo period when seen in the outpatient

setting or at hospital discharge

Inpatient

and

Outpatient

Individual

practitioner

Facility

8. Counseling

regarding ICD

implantation for

patients with LVSD on

combination medical

therapy†‡

Percentage of patients aged ≥18 y with a diagnosis of HF with current

LVEF ≤35% despite ACE inhibitor/ARB and beta-blocker therapy for

at least 3 mo who were counseled regarding ICD implantation as a

treatment option for the prophylaxis of sudden death


practitioner

9. Post-discharge

appointment for heart

failure patients

Percentage of patients, regardless of age, discharged from an inpatient

facility to ambulatory care or home health care with a principal

discharge diagnosis of HF for whom a follow-up appointment was

scheduled and documented including location, date and time for a

follow-up office visit, or home health visit (as specified)

Inpatient Facility


†Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any other

purpose, e.g., pay for performance, physician ranking or public reporting programs.

‡New measure.


• Volume Displacement

– Thoratec

– Novacor

– Heartmate LVAS

– Abiomed

• Axial Flow

– Heartmate II

– Jarvik

• Centrifugal

– CentriMag

– Heartware

Baughman KL, Jarcho JA. NEJM 2007;379(9):846-9.

Mechanical Circulatory Support: Ventricular Assist Devices: Bridge to Tx, Destination Therapy

Medical Therapy for Stage C HFrEF:

Magnitude of Benefit Demonstrated in RCTs

GDMTRR Reduction

in Mortality

NNT for Mortality

Reduction

(Standardized to 36 mo)

RR Reduction

in HF

Hospitalizations

ACE inhibitor or

ARB17% 26 31%

Beta blocker 34% 9 41%

Aldosterone

antagonist30% 6 35%

Hydralazine/nitrate 43% 7 33%

Therapies in the Hospitalized HF Patient (cont.)


When diuresis is inadequate, it is reasonable to

a) Give higher doses of intravenous loop diuretics; or

b) add a second diuretic (e.g., thiazide)

IIa

B

B

Low-dose dopamine infusion may be considered with loop diuretics to

improve diuresis IIb B

Ultrafiltration may be considered for patients with obvious volume

overloadIIb B

Ultrafiltration may be considered for patients with refractory congestion IIb C

Intravenous nitroglycerin, nitroprusside or nesiritide may be considered an

adjuvant to diuretic therapy for stable patients with HF IIb B

In patients hospitalized with volume overload and severe hyponatremia,

vasopressin antagonists may be considered IIb B

Framingham Criteria for Congestive Heart FailureDiagnosis of CHF requires the simultaneous presence of at least 2 major criteria or 1major criterion in conjunction with 2 minor criteria.

Major criteria:· Paroxysmal nocturnal dyspnea· Neck vein distention· Rales· Radiographic cardiomegaly (increasing heart size on chest radiography)· Acute pulmonary edema· S3 gallop· Increased central venous pressure (>16 cm H2O at right atrium)· Hepatojugular reflux· Weight loss >4.5 kg in 5 days in response to treatment

Minor criteria:· Bilateral ankle edema· Nocturnal cough· Dyspnea on ordinary exertion· Hepatomegaly· Pleural effusion· Decrease in vital capacity by one third from maximum recorded· Tachycardia (heart rate>120 beats/min.)The Framingham Heart Study criteria are 100% sensitive and 78% specific foridentifying persons with definite congestive heart failure.

CHF guidelines 2013seminar

Health & Medicine

Transcript of CHF guidelines 2013seminar